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Medical Student Perspectives: Excelling in Clinical Clerkships

Clerkship year is one of the most exciting and challenging years of medical school. We have spent most of our first and second years cramming as much information as possible into our brains without knowing what is clinically important, and what is not. The wards will give you an idea of what information is most relevant in the diagnosis and treatment of the patient as well as burn a mental picture into your mind about a specific disease entity that you learned about from textbooks, but had never seen firsthand.

Approach each new rotation with an open mind, even if you donít think it is the specialty for you. You may have a change of heart. On the other hand, gaining knowledge from other specialties can also be useful for whatever career you choose in the future. For instance, even though you may be set on Ob/Gyn as a career choice, you still need to learn how to manage your Ob/Gyn patients medically, as they can present with complications related to topics covered in internal medicine, such as hypertension or diabetes. Thus, it is still important to pay attention during your internal medicine rotation even though you may be pursing another specialty. This applies to every rotation. The more you see, the more you will remember. Moreover, being an active learner during each rotation will benefit your shelf examination score as well.

To some, starting clerkships may be daunting, but if you follow sound advice you will be able to make the most of your time and learn valuable diagnostic pearls from the attendings and residents. Here are some tips to get you started.

Communicate
In the beginning, it is important to know what the resident and attending expect of you. Schedule a time to sit down with the attending to discuss these expectations when you present a patient in terms of format and key points that he or she would like to hear about during your presentation. Some like to hear the entire history and physical exam while others just want to hear an abbreviated version with the pertinent positives and negatives. Also, schedule some time midway through the rotation to meet with your attending and obtain mid-rotation feedback, go over your progress thus far, and discuss areas where you can improve.

Know your patient. Besides reading the patientís chart and lab data, obtain a full history and physical exam. Thus, it is important to establish a good rapport with your patient. Introduce yourself and respect their privacy. If you ask the right questions, patients are the best sources of information in helping you reach a particular diagnosis. Be aware of all the events pertaining to your patient prior to rounds, talk to the nurses taking care of your patient for an update on overnight events, and anticipate possible diagnosis and management questions that the attending or resident might ask during rounds. Since time is scarce in the morning before rounds, it is advisable to have a mini resource book in your white coat to quickly review relevant points about certain diseases when you have pockets of time. Practice the formal presentation but be ready to present an abbreviated version as well.

Although evaluations are important, a major component of your overall grade is your performance on the shelf exam. Ask upperclassmen who have taken the exam what they recommend in terms of references to use during the rotation and what question books or banks they found helpful for reviewing concepts on the shelf exam. During the rotation, read and practice questions whenever you can. Upperclassmen are also a great resource for advice on choosing rotation sites.

Be a Team Player
Be as helpful as you can to everyone Ė nurses, attendings, residents, patients, and related staff. Be courteous to the clerkship coordinator and secretary, because they are the ones that create your schedules and site preferences, and distribute grades. The resident works closely with the attending and is responsible for devising and managing a treatment plan for your patients. They are also responsible for teaching you and the intern via didactics or informal quizzing.

One of your duties is to keep your residents and interns informed and up to date on patients. Lighten the internsí burden by volunteering for Ďthanklessí duties so that they have time to teach you management strategies pertaining to the patients on your service. Interns are your most natural allies as they themselves were recently students. Although interns may not necessarily be involved in your formal evaluation, they will let the resident know how you are doing. If there is nothing assigned for you to do, you should still ask the resident or intern if there is anything you can do to help them out.

Lastly, do not be a gunner. Attendings and residents do not appreciate this attitude and can spot it immediately. Be a team player by not only helping out the attendings and residents, but also by lending a helping hand to your fellow classmates. Trust me, it will make the long hours you spend on the wards a more pleasant experience. You are there to learn, not step on peopleís toes! If you put in the time and dedication to help out your peers, it may even be recognized and positively reflected in the comments section of your evaluation.

Read!
Always be eager to learn and read up on cases you might see the next day. Know everything there is to know about your patient. Obtain a thorough history and look up relevant labs, tests, and results as soon as possible. Be sure that you can interpret whatever labs or tests you order and be ready to present your assessment and plan for your patient during rounds. I found ACPís Physicianís Information and Education Resourceģ (PIER) useful when devising my assessment and plans. This database is free to all ACP members. There are many resources out there so find one that works for you. Do not be afraid to go back and ask the patient more questions if you feel that you may have missed something.

As for the shelf exam, plan to do some reading everyday, choose sources that solidify your foundations in medicine and test your understanding of concepts with questions. There are several top-rated resources used to prepare for the internal medicine shelf exam; among these are ACPís MKSAP for Students 4 and Internal Medicine Essentials for Clerkship Students 2. On the shelf exam, you will need to read fast (as the vignettes are long) and know your concepts well.

If you have time, read up on articles from newsletters like ACP Internist so that you can share relevant new technologies or interesting research developments pertaining to your patientís management during rounds. If time permits, cite them during your presentation or update of your patient to support why you devised the particular assessment and plan and impress your attending and evaluators!

Stay Organized
You will find that effective organization and time management will greatly benefit you during rounds. In the morning, there is a limited amount of time to get to know a new patient who was admitted the night before and to check up on existing patients for updates on their condition. Before I started my internal medicine rotation, I found it useful to design a simple 1-page template that included all the possible information I might need in a formal presentation of a patient (i.e., H&P, vital signs, labs, test results, overnight events, assessment and plan, etc.). You may find that a clipboard allows you to keep all your papers in order without dog-ears. Some students use note cards to organize clinical information for each patient. Find what works for you and stick with it.

Additionally, it is handy to have a granola or energy bar in your pocket in case you do not have a chance to make it to the cafeteria to eat breakfast or lunchóthis happens more often than you would like to think. This tip will save you from bouts of hypoglycemia.

To conclude, your performance during your rotations is of great interest to residency directors, so do not take it lightly! With that being said, your rotations embody the most interesting and exciting times you may have during medical school. Keep in mind that you are evaluating the specialties as well. Have an open mind, even if you donít see yourself choosing that specialty. The key to getting the most out of your rotation is to always be there to learn, try to see as much as you can, and ask questions. Know your books well and your patients even better. Have fun and good luck on the wards!

Wendy Ho
North Atlantic Representative, Council of Student Members
Albany Medical College, 2010
E-mail: how@mail.amc.edu

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Back to December 2009 Issue of IMpact

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